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Posted: April 20, 2005

Professional Caregiving

The Best Friends Approach

I had an opportunity to visit with a colleague recently as he presented his highly regarded approach to working with dementia patients.

David Troxel and Virginia Bell, an internationally recognized consulting team, and co-authors of four books on dementia care, developed and implemented a communication and relationship approach. Training and consulting on "The Best Friends Approach" is what takes them to all corners of the globe. 

What is a best friend?  If we are lucky, we have had them in our lives and thus have centered much of our lives around their presence, support and care.  I would define a best friend as a caring, loving friend who takes in the entire person, faults and all, unconditionally supporting, giving and taking. A best friend knows as many things about you as a family member does, maybe even more.

This approach has been a leading one for over two decades, paving the way for many others who have proposed that care for patients should be about focusing on strengths, giving the person opportunities to be successful and loved, in spite of the failings of his memory and skills.  Whether care is provided in one's home, in an adult day center, or a skilled or assisted living facility, this particular philosophy is both a breath of fresh air, and easily transferable, because all of us have had the experience of being or having been a best friend. 

One might think that because we "know" what it is like to be a best friend, there is no training necessary...  but in fact, this is not the case.  The traditional model has been one of controlling, authoritarian styles that have evolved from our paternalistic medical world from long ago.  The typical way of following doctors' orders, having problems diagnosed, being compliant with treatment plans and asking few questions is still much practiced. 

In order to create a caring and loving "Best Friend" environment one has to have a "knack," which he defines as "the art of doing difficult things with ease." Caring for people with dementia can be difficult and stressful, and the primary message here is that we need to learn to "allow" for the behavioral and functional difficulties as if the people having them were our best friends.  Training ourselves away from anger, frustration and the visible body language that communicate negative feelings is more easily said than done, and thus, one who has a knack knows how to handle the toughest situations without effort.

The regular use of compliments to residents and staff, alike, knowing their life story -- at least 100 details in this person's life -- as David and Virginia suggest, will equip staff to relate and engage more deeply, more like a Best Friend, with patients and colleagues. Sincerity, humor, asking the residents their opinions, taking the blame when something goes wrong, are all about putting the resident in the spotlight, praising them, and helping them feel as competent as possible in every situation.

David reminds us about some important communication tips: not to argue, confront or correct the person with Alzheimer's disease for whom we care, always remembering that the goal of excellent care is to move the person's emotional reality from the negative to the positive, from loneliness to connectedness, from anxiety to contentment, from anger to calm.

 He suggests some tips for hiring staff with "knack:"

  • Look for non-traditional staff (with special talents or hobbies ); i.e., persons who can be trained in the area of care, but who have a passion they bring to the job.
  • Escort them around your center and see how they relate to individuals and staff as a whole.
  • Invite your present team to be part of assessing the new candidate, so your team members are invested.
  • Check for creativity and humor in your interviewing process.
  • Ask them about their personal best friends, see how they describe them, then tell them about this approach to working with persons with dementia.

    Hiring staff should be an innovative activity, financial and staff investment should be put into training, and wages should be competitive for all levels of staff.  New hires should be person-oriented, comfortable working/playing on teams, enthusiastic and take initiative in their work.

    When the work environment is pleasant, and strength focused, morale improves, staff retention increases and clients will reflect a positive atmosphere with smiles, and  healthier relationships with others and staff, alike.

    For more on this subject see:  (The Eden Alternative - William Thomas, MD; Validation Therapy - Naomi Weil; and The Positive Interactions Program - Sylvia Nissenboim and Christine Vroman),, to name a few.


Sylvia Nissenboim is a licensed clinical social worker and who has been working in the field of adult day services in the St. Louis area. She is the director of four adult care and enrichment centers for the American Red Cross and also operates a personal and professional coaching firm, LifeWork Transitions, specializing in caregiving concerns, adult day care management and other aging services, such as virtual coaching and family care giving support groups. She co-authored The Positive Interactions Program, is a national speaker, and has served as president of the Missouri Adult Day Care Association and as a member of the Missouri Governor's Advisory Council on Aging..

© 2005 Pederson Publishing, Inc. All Rights Reserved.
Commercial use, redistribution or other forms of reuse of this information is strictly prohibited without the prior written permission of Pederson Publishing.

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